The hepatitis C virus (HCV) epidemic in the U.S. is concentrated in people who inject drugs (PWID). Increasing reports of HCV including outbreaks of HCV in young adult PWID in non-urban locales have prompted concerns about an expanding epidemic. Several investigations suggest that that these spikes in HCV infection are linked to sharp increases in prescription opiate use that has been trending in the U.S, and which have resulted in young adults transitioning from prescription opiates to injection use, particularly heroin. Young adult PWID in non-urban areas may be at increased risk of infection, from the combination of high viral infectivity and high prevalence of HCV in injecting groups, together with a lack of knowledge regarding infection routes and effective prevention. New Mexico is one of the states leading recorded increases in HCV in young adults, ranking 2nd in the CDC's Emerging Infections Program (EIP), Hepatitis Surveillance Demonstration Sites project, in 2011 for the number and rate of HCV cases reported. Heroin, prescription opioids, and other drugs are also accounting for this state having one of the highest overdose rates in the country. Between October 2013 and March 2014, the New Mexico Department of Health recorded 211 cases of HCV among young adults in a pilot surveillance study, demonstrating the gravity of the problem. To address the need for prevention, care and treatment services against HCV in this population, we propose epidemiological and service uptake research in two regions of New Mexico where young adult PWID have been impacted by drug use and HCV. We will initiate a prospective cohort study of young adult non-urban PWID who will be recruited and followed in two health regions of New Mexico (the South West and North East) to: (1) gather epidemiologic data on risk behaviors, drug use patterns, injection networks, prevention needs, and health service utilization; (2) to refer young adult PWID to HCV care services, as well as other prevention and treatment opportunities including harm reduction and drug treatment, and assess rates of successful linkage, including the cascade of care; (3) to examine factors that may contribute to non-treatment, poor adherence, and failure to achieve SVR among young adult PWID with chronic HCV infection; and (4) assess reinfection events among young adult PWID who are treated for HCV and achieve SVR. Our proposal, which we refer to in this application as New Mexico H-TIPS, will also include testing and referrals for HIV and HBV co-infections as well. A collaborative group of public health and clinical specialists linked with a strong prevention and clinical service infrastructure in New Mexico will ensure successful implementation of this research. Results from this proposed research will impact a diverse young population disproportionately at risk for HCV and reduce health disparities in a region highly impacted by drug use and HCV.